Noninvasive Human Brain Stimulation: Timothy Wagner, Antoni Valero-Cabre, and Alvaro Pascual-Leone

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Annu. Rev. Biomed. Eng. 2007.9:527-565. Downloaded from arjournals.annualreviews.org

by HARVARD UNIVERSITY on 10/18/07. For personal use only.
Noninvasive Human Brain

Stimulation
Timothy Wagner,1 Antoni Valero-Cabre,1,2,3
and Alvaro Pascual-Leone1,4
1
Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center,
Department of Neurology, Harvard Medical School, Boston, Massachusetts 02215;
email: [email protected]
Laboratory of Cerebral Dynamics, Plasticity and Rehabilitation, Department of

Anatomy and Neurobiology, Boston University School of Medicine, Boston,
Massachusetts 02218
LPNC, CNRS Unit 5105-ERT-Treat Vision, Department of Neurology,

Fondation Ophtalmologique Rothschild, 75019 Paris, France
Institut Guttmann dRehabilitacio, Universitat Autonoma, Barcelona, Spain
Annu. Rev. Biomed. Eng. 2007. 9:52765
Key Words
First published online as a Review in Advance on

April 19, 2007
TMS, tDCS, electromagnetism, neural networks, modeling,

neurophysiology, neuromodulation, therapeutic applications,
rehabilitation
The Annual Review of Biomedical Engineering is

online at bioeng.annualreviews.org
This articles doi:
10.1146/annurev.bioeng.9.061206.133100
c 2007 by Annual Reviews.
Copyright
All rights reserved
1523-9829/07/0815-0527$20.00
Abstract
Noninvasive brain stimulation with transcranial magnetic stimulation (TMS) or transcranial direct current stimulation (tDCS) is
valuable in research and has potential therapeutic applications in
cognitive neuroscience, neurophysiology, psychiatry, and neurology.
TMS allows neurostimulation and neuromodulation, while tDCS is
a purely neuromodulatory application. TMS and tDCS allow diagnostic and interventional neurophysiology applications, and focal neuropharmacology delivery. However, the physics and basic
mechanisms of action remain incompletely explored. Following an
overview of the history and current applications of noninvasive brain
stimulation, we review stimulation device design principles, the electromagnetic and physical foundations of the techniques, and the
current knowledge about the electrophysiologic basis of the effects.
Finally, we discuss potential biomedical and electrical engineering
developments that could lead to more effective stimulation devices,
better suited for the specic applications.
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Contents

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DEVICE DESIGN PRINCIPLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Magnetic Stimulators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DC Stimulators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tracking Systems: Localizing the Structures Targeted
in the Subjects Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PHYSICS AND FIELD MODEL FOUNDATIONS . . . . . . . . . . . . . . . . . . .
TMS Foundations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DC Stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Modeling in the Presence of Pathologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ELECTROPHYSIOLOGY OF STIMULATION. . . . . . . . . . . . . . . . . . . . . .
INSIGHTS FROM ANIMAL EXPERIMENTS . . . . . . . . . . . . . . . . . . . . . . .
MERGING TMS WITH OTHER BRAIN-IMAGING METHODS
IN HUMANS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TMS and EEG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TMS and PET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TMS and SPECT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TMS and NIRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TMS and fMRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
tDCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FUTURE DIRECTIONS AND CONCLUSIONS . . . . . . . . . . . . . . . . . . . .
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INTRODUCTION
The past decade has seen a rapid increase in the application of noninvasive brain
stimulation to study brain-behavior relations and treat a variety of neurologic and
psychiatric disorders. Noninvasive brain stimulation provides a valuable tool for interventional neurophysiology applications, modulating brain activity in a specic,
distributed, cortico-subcortical network so as to induce controlled and controllable
manipulations in behavior; as well as for focal neuropharmacology delivery, through
the release of neurotransmitters in specic neural networks and the induction of focal gene expression, that may yield a specic behavioral impact. Noninvasive brain
stimulation is a promising treatment for a variety of medical conditions, and the number of applications continues to increase with the large number of ongoing clinical
trials in a variety of diseases. Therapeutic utility of noninvasive brain stimulation
has been claimed in the literature for psychiatric disorders, such as depression, acute
mania, bipolar disorders, hallucinations, obsessions, schizophrenia, catatonia, posttraumatic stress disorder, or drug craving; neurologic diseases, such as Parkinsons
disease, dystonia, tics, stuttering, tinnitus, spasticity, or epilepsy; rehabilitation of
aphasia or of hand function after stroke; and pain syndromes, such as those caused
by migraine, neuropathies, and low-back pain; or internal visceral diseases, such as
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chronic pancreatitis or cancer. Even though such claims are insufciently supported
by clinical trial data to date, the potential signicance of noninvasive brain stimulation
is huge, affecting a large number of patients with debilitating conditions. Unfortunately, despite the rapid growth in interest and applications of these techniques, the
physics and basic mechanisms of action remain incompletely explored, and biomedical engineering approaches that could lead to more effective stimulation devices,
better suited for the specic applications, require careful consideration (for a more
extensive history of noninvasive brain stimulation, please see the Supplemental Appendix, follow the Supplemental Material link from the Annual Reviews home page
at http://www.annualreviews.org).
The two most commonly used techniques for noninvasive brain stimulation,
transcranial magnetic stimulation (TMS) and transcranial direct current stimulation
(tDCS), take advantage of different electromagnetic principles to noninvasively inuence neural activity (Figure 1). TMS is a neurostimulation and neuromodulation
application, whereas tDCS is a purely neuromodulatory intervention. TMS uses the
principle of electromagnetic induction to focus induced currents in the brain. These
currents can be of sufcient magnitude to depolarize neurons, and when these currents are applied repetitively [repetitive transcranial magnetic stimulation (rTMS)]
they can modulate cortical excitability, decreasing or increasing it, depending on the
parameters of stimulation, beyond the duration of the train of stimulation (1). During
tDCS, low-amplitude direct currents are applied via scalp electrodes and penetrate
the skull to enter the brain. Although the currents applied do not usually elicit action
potentials, they modify the transmembrane neuronal potential and thus inuence the
level of excitability and modulate the ring rate of individual neurons in response
to additional inputs. As with TMS, when tDCS is applied for a sufcient duration,
cortical function can be altered beyond the stimulation period (2).
TMS: transcranial
magnetic stimulation
tDCS: transcranial direct
current stimulation
rTMS: repetitive
transcranial magnetic
stimulation
DEVICE DESIGN PRINCIPLES

Magnetic Stimulators
Magnetic stimulators consist of two main components (Figure 2): a capacitive highvoltage, high-current charge-discharge system and a magnetic stimulating coil that
produces pulsed elds of 14 Tesla in strength with durations of approximately a
millisecond for single-pulse stimulators and a quarter of a ms for rapid stimulators.
The charge-discharge system is composed of a charging unit, a bank of storage
capacitors, switching circuitry, and control electronics. Without the switching circuitry and control electronics, the circuit is essentially a parallel RLC circuit, where
the resistance, R, and the inductance, L, are both set to the lowest practical values to
minimize heating while generating the desired waveform (mono-, bi-, and polyphasic
devices exist, but the rst two are most common). Single-pulse devices refer to those
capable of delivering a stimulus every few seconds. Reverse charging or ringing in
the circuit is prevented by placing a diode thyristor between the capacitor, C, and
the inductor, L, thereby increasing the current decay time and eliminating reverse
currents. In repetitive stimulators, the essential circuitry remains the same, except
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Figure 2
s
Coil
+
V
D
C
R
RV
b
(a) A simplied circuit

diagram of a single-pulse
magnetic stimulator. (b) A
circuit diagram of a tDCS
stimulator unit. V =
voltage source, s = switch,
C = capacitator, D =
diode, R = resistor, T =
thyristor, RV = variable
resistor.
Anode
+
V
Cathode
modications are made to the switching system to allow pulse rates of many times
per second (herein thyristor switching schemes can be used to recover energy to the
capacitive charging unit and increase charging rates). Recent generation devices allow upward of 100 Hz stimulation frequencies. The difculties in designing these
machines relate to overcoming the high-voltage (400 V to more than 3 kV), highcurrent (4 kA to more than 10 kA), and high-power (where over 500 J of energy can be
discharged in under 100 s, or approximately 5 MW) demands on the circuitry while
optimizing the device components to generate the appropriate coil current waveforms for neural stimulation. These topics are addressed in further detail elsewhere
(e.g., 3).
The second key hardware component of magnetic stimulators is the current carrying coil, which serves as the electromagnetic source during stimulation. Design
of the coil is critically important because it is the only component that comes in
direct contact with the subject undergoing stimulation, and the coils shape directly
inuences the induced current distribution and, thus, the site of stimulation (4, 5).
Although many researchers have explored unique coil designs for increased focality
(69) or specied stimulation (1012), the most common coils currently used are
Figure 1
(a) During TMS, a time-pulsed current is discharged through a hand-held coil. The resulting
time-varying magnetic eld is focused onto underlying neural tissue. This eld induces
stimulating eddying currents in the tissue such that the neural activity can be affected during
and after stimulation. The patient is shown wearing a device that can be used to predict the
location of stimulation relative to the TMS coil, which is tracked via the camera device (inset);
see text for more information about tracking systems. (b) During tDCS, a constant
low-amplitude DC current is applied to the cortex via surface-mounted scalp electrodes.
Neural activity can be affected during and after stimulation. (c) Effects as a function of TMS
source strength. (d ) TMS effects on event-related potentials.
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single circular loop or gure-eight shaped (i.e., two circular coils in parallel, also
referred to as double or buttery coils; Figure 1). They are constructed from tightly
wound copper wire, which are adequately insulated and housed in plastic covers
along with feedback temperature sensors and safety switches. The choice of copper is
primarily driven by its low electrical resistance, heat capacity, tensile strength, availability, and relative low cost. Exploration of other materials seems desirable as it might
lead to means to construct smaller, and thus more focal, stimulation coils. Current
limits are reached when the self-generated repulsive coil Lorentz forces overcome
the tensile strength of the copper coils and cause them to shatter (5). Commercially
available coil diameters range from 4 to 9 cm, with anywhere from 10 to 20 turns
(typical coil inductances range from approximately 15H to approximately 150 H).
Some have explored the design of coils to attain subcortical stimulation (13, 14).
Yet, it has been shown analytically that TMS currents will always be maximum at the
cortical surface (15). However, it could be possible to develop a coil design where
the rate of decay from the surface is attenuated, such that deeper structures can be
stimulated (simultaneously with the overlaying cortical surface) without the need of
excessive eld strengths (13, 14). More recently, researchers have been investigating
the use of conducting shields, placed between the TMS coil and the subjects head,
to alter and focus the stimulating elds (16, 17). The use of nonlinear coil materials
has also been explored, but has not been implemented commercially.

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DC Stimulators
Currently, DC stimulation is applied via a constant current source attached via patch
electrodes (surface areas from 2535 cm2 ) to the scalp surface (Figure 1b). Currents
usually range in magnitude from a constant 0.5 to 2 mA, and are applied from seconds
to minutes. The electrodes can be simple saline-soaked cotton pads or specically
designed sponge patches covered with conductive gel. There is no complex circuitry
comprising the stimulators, and in its simplest form a DC source is placed in series with
the scalp electrodes and a potentiometer to adjust for constant current (Figure 2b).
Tracking Systems: Localizing the Structures Targeted

in the Subjects Brain
The current TMS standard for predicting the location of neural stimulation is based
on image-guided frameless stereotaxic systems similar to those used for intracranial
navigation during minimally invasive neurosurgery. No such system currently exists
for tDCS; however, it is likely systems will be developed similar to those for TMS
(with integrated eld solvers), described below.
The frameless stereotaxic systems for TMS rely on the subjects head MRI data
and coil geometry to digitally track the coil position relative to the subjects head and
register the predicted stimulation location in MRI space (Figure 1a). These systems
work by rst loading the subjects MRI data into the computer guidance system, then
registering surface ducial points of the subjects head within MRI space relative to a
xed optical or electromagnetic sensor on the subjects head, and nally tracking the
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stimulating coil relative to the surface ducials and a sensor afxed to the coil. Some
systems exist that implement spherical model solutions to approximate current distributions in the cortex. Although these prediction methods are a major improvement on
earlier methods, they ignore the electromagnetic interaction between the stimulating
elds and the actual tissues that comprise the physical site of stimulation and provide
no information as to the true stimulating current distribution induced within the
subjects brain. It seems critically necessary to develop an integrated electromagnetic
eld solver tracking system to address these limitations, particularly given ndings of
current distributions in the setting of brain pathologies (see below).
PHYSICS AND FIELD MODEL FOUNDATIONS

TMS Foundations
During TMS, a time-pulsed magnetic eld is focused on cortical tissue via a handheld coil to induce currents in the tissue. Phantom (4, 1821), animal (2224), and in
vivo human studies (25) have provided important information on the induced current
distributions. However, current technical limitations preclude the complete characterization of the electromagnetic eld distributions via this type of experimentation
and necessitate the development of theoretical modeling studies.
Numerous theoretical models have been developed to provide a view of the electromagnetic eld distributions generated in biological tissue during TMS (2636).
Most models have been developed and solved with the nite element method, which
is developed by segmenting the head tissues and dening tissue boundaries, assigning tissue conductivities and source parameters, and identifying current and voltage
boundaries in the model region. The majority of earlier models were based on simplied shapes, such as innite half-planes and perfect spheres. These models are
typically solved for the electric eld in terms of the time derivative of the magnetic
vector potential owing to the coil current source and the secondary Laplacian eld
that results from the build up of charge at the conductive boundaries. Many of these
earlier models are being reevaluated with the increased precision of more realistic
head models, revealing important insights. For example, the simplied geometries of
early models argued for the absence of currents normal to the cortical interface (20,
30, 37) and limited effects of surrounding tissues or altered anatomies (30, 32), but
such conclusions have since been proven inaccurate by more realistic head models
(33, 35, 38, 39). Results based on these simplied models have been misinterpreted in
their application to clinical practice. For example, the conjecture that radial currents
are absent during TMS has inuenced the interpretation of clinical studies related
to the generation of indirect ( I ) and direct (D) waves and justied the claim that interneurons tangential to the cortical surface are preferentially stimulated (40). However, such clinical interpretations need to be reevaluated in light of recent modeling
work.
In 2002, Starzynski et al. implemented a more realistic head-shaped model consisting of a single homogeneous tissue, and they showed the importance of the head
geometry in determining the nal induced current density via a T-omega solution
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FEM: nite element model

CAD: computer-aided
design
19:2
method (41). In 2003, Nadeem et al. presented one of the most comprehensive models
of TMS, demonstrating the importance of accounting for the actual head model geometry and tissue compartmentalization while calculating the induced current density
magnitudes via the three-dimensional impedance method (36). The importance of the
tissue properties were further highlighted by Miranda et al. who showed the effects
of heterogeneities and anisotropies in a three-sphere mode in perturbing the TMSinduced stimulation currents (42). Wagner et al. generated a sinusoidal steady-state
nite element model (FEM) based on an MRI-guided 3-D computer-aided design
(CAD) rendering of the human head that included inhomogeneties, anisotropies, and
additionally tested for the impact of alpha dispersion in tissues via a modied T-omega
solution method (39). Although earlier TMS models only accounted for variations
in tissue conductivities, alpha dispersion predicts that the actual low-frequency permittivity value of biological tissues could be high enough that displacement currents
be relevant during TMS stimulation and the tissue permittivities can thus not be ignored (39). In this context, it is important to note, that during TMS, the main power
components of typical current pulses are below 10 kHz (34), and classically the permittivity values implemented during TMS modeling generate quasi-static solutions
with negligible displacement currents such that the permittivities can be disregarded.
However, with the permittivity values predicted via alpha dispersion, the charge relaxation times of the tissue can be of the same order of magnitude as the timescale
of the stimulating current source such that displacement currents need to be considered. Wagners model was analyzed with permittivities spanning the magnitude
range from 102 107 of the permittivity of free space for the various tissues, concluding that displacement currents are negligible up to permittivity magnitudes in the
range of 105 of the permittivity of free space. Similar to other models, the maximum
current density in the gray matter was found along the CSF/gray matter interface
(Figure 3a displays the solution for when displacement currents were negligible).
The ratio of maximum cortical current density to source strength ranged from (5.13
108 A/m2 in the cortex)/(1 A/s source) in solutions with negligible displacement
currents, to (5.51 107 A/m2 in the cortex)/(1 A/s source) for the tissues modeled
with permittivity values in the 107 magnitude range, a value of 2.9 A/m2 to 31.1 A/m2
for a 5 kHz 1800 A peak current source (5.65 107 A/s). Stair step jumps in the
Figure 3
(a) Plots of the current density magnitudes on the cortical surface for the TMS (left) and tDCS
(right) solutions. The location of the stimulation source is depicted to the right of the current
density magnitude solutions, both graphically over the 3-D models (top) and with the source
shown above the solution (bottom). The coil (gray) represents the TMS solutions, whereas the
anode (red ) and the cathode (black) represent the tDCS solutions. (b) Current density
magnitude evaluated along an evaluation line in the TMS and tDCS solutions. Note that the
current density magnitude varies with the conductivity of the tissues. The insets show the
mesh model with the current density magnitudes plotted on the surface of the cortex with the
center evaluation lines shown intersecting the tissues. (c) Current density vector plots on the
gray matter surface for the TMS and tDCS solutions. Note that the scales are normalized to
the corresponding stimulation method, where the maximum for TMS is 2.9 A/m2 and the
maximum for tDCS is 0.103 A/m2 at the anode. Modied from References 44, 57.
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current density magnitude were seen at the tissue boundary interfaces in every solution and correlated with the magnitude of the complex conductivity of the tissue
(complex conductivity = + j) (Figure 3b). The maximum cortical current
surface area, dened as the surface area on the cortex where the current density was
greater than 90% of its maximum, ranged from 107119 mm2 for the varied solutions, with slightly larger areas seen in the case of higher tissue permittivities. These
surface areas are much larger than those predicted by simplied models, which claim
functional stimulation areas as low as 5 mm2 . For all of the solutions, the location of
the maximum cortical current density did not correspond directly to the location of
the normal projection from the gure-eight-shaped coils center, but this projection
consistently intersected the cortex within the maximum cortical current surface area.
The induced current density variation and vector behavior seen in the tissues were
consistent with those of previous studies, where the vector orientation followed a
gure-eight path with the greatest irregularity at the tissue boundaries (26, 37, 39)
(Figure 3c).
Future extensions of these methods could be used to develop a eld solver coupled to a MRI frameless stereotaxic tracking system to predict the location of peak
current density in the cortex and the relative current density distribution to neural
orientations. Eventual combination of such a model with information gathered from
diffusion spectrum imaging might prove particularly valuable in guiding optimization
of induced current directions. In any case, it seems clear that there remains an unmet
need for further in vivo tissue studies to ascertain the proper electromagnetic tissue
properties to implement during TMS eld model studies.

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DC Stimulation
tDCS is a steady ohmic conduction process. To have a full understanding of the
injected current distributions, one must either make direct measurements of the
current distributions in either an animal or human subject under varied tDCS conditions with a sparse multipolar electrode grid or by constructing similar continuum
electromagnetic models that take into account the true head anatomy, tissue properties, and electrode properties. Depth electrode recordings have been made to access
the potential differences found during DC stimulation in three patients undergoing
presurgical evaluation for epilepsy, nding potential values in the cortex ranging from
6.4 to 16.4 mV/cm for a 1.5 mA source (43), but more detailed experiments to more
fully discriminate the eld have yet to be made. Thus, herein we analyze multiple
continuum models of electrical stimulation to more fully depict the injected current
distributions.
A simplied resistor model provides an intuitive glimpse of the mechanism of
DC stimulation (44), which predicts axial and tangential cortical current densities of
0.093 and 0.090 A/m2 when approximating a constant area of stimulation (modeled
with 7 5 cm electrodes in this case with 1 mA current strength). These current
densities are of the same order of magnitude as those seen by Bindman to alter the
level of neural excitability (45, 46). However, the true current distributions and the
effects of the anatomical, tissue, and electrode variations need to be explored through
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continuum electromagnetic models of the tDCS head system. Few electromagnetic

models of tDCS presently exist, and thus numerous researchers rely on models of
transcranial electrical stimulation (4751), which do not completely account for the
stimulating conditions used clinically or analyze the problem reciprocally based on
early electroencephalography (EEG) models (48).
Transcranial electrical stimulation (TES) is similar in nature to tDCS in that an
electrical source is used to stimulate cortical neurons; however, the electrodes applied,
current sources used, and desired effect all differ. TES employs smaller electrodes
than tDCS scalp electrodes, leading to much larger stimulating current densities
(oftentimes applied as pulse trains, time-varying signals, or constant currents) compared to tDCS (applied as a time-invariant constant amplitude currents ramped on
only at the onset of stimulation). Moreover, TES actively evokes action potentials
from the underlying neural substrate, whereas the effects of tDCS alter the overall
excitability of the neural response. The use of TES in awake humans is limited owing
to the induced pain resulting from strong activation of skin and scalp pain receptors. TES is typically applied to evaluate active CNS functions during neurosurgery,
whereas tDCS is used to modulate cortical activity following stimulation (2) (52).
Although it differs signicantly from tDCS, electromagnetic models of TES provide
signicant data about the current density distributions expected during tDCS. The
quasi-static eld approximation, which is implemented with both TES and tDCS
electromagnetic models, implies conservation and linearity of the electric eld solution such that different electric eld and current density values can be linearly
extrapolated from similar situations.
Multiple models of TES exist (4751). Similar to tDCS, the frequencies of the
stimulation source are such that they can be considered electroquasi-static (save for
the possibility of alpha dispersion effects discussed above) in nature and evaluated in
terms of the electric potential (), by solving Laplaces equation,
(i ) = 0,
EEG:
electroencephalography
TES: transcranial electrical
stimulation
(1)
where i is the conductivity of the tissue. A number of common results relevant to

tDCS stimulation have been demonstrated: (a) the skulls high resistivity attenuates
the currents reaching the cortex, which instead are primarily shunted along the scalp
surface; (b) the geometry of the head and the tissue electromagnetic properties play
a signicant role in determining the nal eld distribution; and (c) the electrode
placement is critical to determining the nal eld distribution.
Wagner et al. have produced a new FEM specic to tDCS (Figure 3), which tested
various electrode montages used in clinical investigations and analyzed the role that
tissue heterogeneities and anatomical variations play on the nal current density distributions (44). For all of the solutions, similar trends, captured in TES modeling
and enumerated above, were seen. The current density magnitudes varied substantially throughout the tissues and stair step jumps in the current density occurred at
each tissue boundary reective of the varied tissue conductivities (Figure 3b). While
varying the electrode placement and keeping a constant current source (1 mA/35 cm2
surface electrode area), the maximum local cortical current densities ranged from
0.077 to 0.20 A/m2 (note that separate maximums were found on the cortical surface
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in the region of both the cathode and the anode, but obviously of reversed polarity),
whereas scalp current densities ranged from 8.85 to 17.25 times larger in magnitude than the cortical current densities (Figure 3a). While varying the electrode area
(from 149 cm2 with a 1 mA constant current) and keeping the placement xed (anode over the right M1 and cathode over the left supraorbital), the maximum cortical
current densities ranged from 0.081 to 0.141 A/m2 in a nonlinear fashion, reective of the relative anatomical/geometrical effects on stimulation current densities
(Figure 3c). The shunting (i.e., the ow of current along the scalp surface as opposed
to the cortex) effects were considerably larger for the 1 cm2 electrodes compared to
the other montages, where current densities in the skin were as much as 86 times
greater than those seen in the cortex for the 1 cm2 electrodes compared to a factor
of 8.56 for the 49 cm2 electrodes. Essentially, greater shunting occurs with smaller
electrode areas, indicative of the varied resistive paths. This is important when one
analyzes the results of earlier tDCS studies that implemented varied electrode types,
of varied geometries, often with mixed results, quite possibly owing to this shunting
effect. Although the cortical current density magnitudes are far lower than action
potential thresholds from controlled electrical stimulation experiments of cortical
neurons [0.079 to 0.20 A/m2 compared to 22 to 275 A/m2 (53)], these tDCS magnitudes have been shown to inuence spontaneous activity and characteristics of the
evoked response from cortical neurons (45, 46, 54). This suggests that the mechanisms of action of tDCS may be quite different from that of TMS, TES, direct cortical stimulation, or even deep brain stimulation, even if behavioral effects may appear
similar.

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Modeling in the Presence of Pathologies

With TMS, changes in the tissue anatomy and electromagnetic properties have been
shown to alter the TMS-induced stimulating currents in both phantom and modeling studies (39, 42, 55, 56). As such, continuum eld models provide researchers
with a means to explore the effects of pathological alterations in the cortex on the
TMS-induced and tDCS-injected stimulating current densities. Wagner et al. (57)
compared the TMS eld distributions in the healthy head models with those resulting
from electrical tissue property and anatomical alterations caused by stroke (Figure 4),
and similar comparisons were made for other pathologies (e.g., atrophy, tumor) and
tDCS current densities (44). For each of the pathologies, the TMS-induced and
tDCS-injected currents were signicantly altered for stimulation proximal to the
pathological tissue alterations for all of the models analyzed. The current density
distributions were modied in magnitude, location, and orientation such that the
population of neural elements that was stimulated was correspondingly altered. The
main reason for this perturbation is that the altered distribution of brain tissue modies the conductivities in the pathological regions and effectively provides paths of
altered resistance along which the stimulating currents ow. These cortical current
density perturbations could prove to be dangerous or, at the very least, lead to unreliable, erroneous results if guided by models that do not account for the electromagnetic
tissue interactions.
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Healthy brain
b Gray matter
Stroke model

a CSF
0.5
1.0
Relative current density magnitude (mA/cm2)

Figure 4
(a) Current density vector distribution in the CSF, comparing a healthy head model and a
stroke model. Note that in the CSF, the current is directed from its predictable course in the
healthy head model toward the underlying stroke borders. (b) Current density vector
distribution displayed on the cortical surface for healthy head versus stroke models. In the
stroke model, the current density vector distributions deviate from predictable gure-eight
distributions that are seen in the healthy head model to conform to the infarction boundaries.
The current vectors became more perpendicular to the stroke boundary along its border and
particularly focused at the corners where the areas of maximum cortical current density were
found. Modied from References 44, 57.
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ELECTROPHYSIOLOGY OF STIMULATION

Although so much is still unknown about the electromagnetics of TMS and tDCs,
even less is known about the neural mechanics of activation. Most models of neural
stimulation are mathematical extensions of the Hodgkin & Huxley model. Of these,
the one that is most accepted and cited for TMS is the Roth peripheral nerve model, a
modied active-cable-type model (29, 30, 5860). This model is similar to peripheral
nerve models of electrical stimulation (6163).
The passive cable model that is the foundation for the Roth model is based on
classic transmission line theory, where the transmembrane potential, V, can be represented by the following equation:
2
V
2V
,
V =
x2
t
(2)
where = rrmi , = c m rm , rm is the membrane resistance times a unit length, c m is

a membrane capacitance per unit length, and ri is the axoplasm resistance per unit
length.
The passive cable model (Equation 2) can be altered by adding an activating
function to represent an external current source, as seen during electrical stimulation,
or by adding the induced electric eld, as seen during TMS. Here, the equation is
altered to include a TMS source:
2
2
2V
V
2 A
+
V
=
x2
t
xt
(3)
where A
represents the induced electric eld. This is similar to electrical stimut
lation models that include activating functions (62). This model predicts conduction
along the membrane when the activating function is below the neural threshold.
To further increase the detail of the model, one could include the active properties
of the axon by implementing the Hodgkin & Huxley model (64), which includes the
voltage/time-dependent sodium and potassium channels represented by g K and g Na
(conductances per unit area for sodium and potassium), respectively; the static leakage
channel represented by g L ; and the Nernst potential for the sodium, potassium, and
leakage ions represented by ENa , E K , and E L , respectively. With these additions, the
nal equation of Roths model is
2V
V
2A
g L (E L V) g Na (ENa V) g k (V E K ) = Cm
+ 2
,
(4)
2
x
t
xt
where = 2a12 r , a is the axon radius, and Cm is given as capacitance per unit area.
i
Much work in the eld of electrical stimulation has been done by Rattay (62) and
others based on similar theoretical models.
According to Roths model, the site of neural stimulation (the initiation of action potentials) is found where the spatial derivative of the induced electric eld is
maximum. One consequence is that the coil hot spot of a gure-eight coil does not
correspond to the optimal site of peripheral nerve stimulation. Predictions based on
this model have been assessed experimentallyclearly agreeing in some studies (65)
but not in others (66). Finally, it should be clear that this model pertains only to
long peripheral nerves and there is no justication to extend this model to cortical
2
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neurons. In fact, if the same eld parameters used for this model were used for cortical neurons, the spatial gradients of the electric eld would be negligible due to the
cortical neurons short length except at locations of axonal bends.
Another model that more accurately depicts cortical neurons is the cable model
developed by Nagarajan (6770), which, by incorporating boundary-type equations,
begins to account for the smaller size, branching, and terminal endings found in
cortical neurons. With this model there are two activation functions, one owing to
the boundary elds and one owing to the induced electric eld gradient along the
neural ber axis. With this increased complexity, the spatial derivative of the induced
electric eld is not the primary factor in predicting the activation site as it was in the
Roth model; instead, the eld effects at the boundary dominate. In the Nagarajan
cable model, the excitation site is located at the axon terminals (bouton locations) or
at the cell body, where the neural axon begins. According to the model for short
axons with sealed ends, excitation is governed by the boundary eld driving function
which is proportional to the electric eld (70). In the eld of electrical stimulation,
similar models have been produced that render similar results (dependent on the
stimulus waveform) (63), but have not yet fully explored the effects of DC currents.
There have been few attempts to explain the biophysical mechanisms of TMS
stimulation and we are unaware of any relevant biophysical models of altered membrane excitability owing to weak DC currents in TMS. However, Kamitani et al. (71)
generated a model to offer insight into the physiology of TMS stimulation. With a realistic cell model that took into account the dendritic aborization, synaptic inputs, and
the various densities of the sodium, potassium (slow and fast channels), and calcium
channels, they were able to show a few key results, most notably, that the induced
current within the neurons was directly related to the electric eld along the neuron
path. Without a synaptic background, magnetic stimulation rarely reached threshold,
whereas with a background of synaptic inputs, magnetic stimulation brought about
burst ring followed by an extended silent period. Bursting was brought about by an
inux of Ca2+ ions followed by the opening of Ca2+ -dependent K+ channels, which
would then limit the effects. Such a result could be the cause for the post-stimulatory
effects of TMS via long-term potentiation mechanisms.
With both tDCS and TMS, electrophysiological studies have been completed
to explore the effects of the electromagnetic elds on the cortices and the neural
elements. In 1956, Terzuolo et al. studied the effects of DC currents on neural preparations and the relative orientations of current to the axon. They found that currents as
low as 3.6 108 injected across the preparation region could change the frequency
of ring, even though they did not directly initiate an action potential (72). In the
1960s, Bindman showed that currents as low as 0.25 A/mm2 applied to the exposed
pia by surface electrodes (3 A from 12 mm2 saline cup on exposed pia surface) could
inuence spontaneous activity and the evoked response of neurons for hours after
just minutes of stimulation in rat preparations (45, 46, 73). Purpura et al. (54) showed
similar effects in cat preparations for currents as low as 20 A/mm2 from cortical
surface wick electrodes ranging in area from 1020 mm2 . In 1986, Ueno et al. completed work with neural preparations and time-changing magnetic elds to ascertain
their effects on action potentials. However, constraints with the experimental design
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originating from a resistor that was impaled into the neural preparation throughout
the experiments (74) limit the impact of this work. Maccabee et al. (75) studied the use
of peripheral nerve preparations to represent cortical ber bends (bent ber model)
and found excitation at the terminations takes place at much lower thresholds and it
occurs at a site within the peak electric eld, similar to the cable models of Nagarajan (70). McCarthy & Hardeem (76) conducted a number of experiments with neural
preparations and pulsed toroids, and they came to the controversial conclusion that
capacitive, not inductive, effects were the cause of magnetic stimulation. Although,
they implemented sources outside of the power spectrum of typical stimulators, their
results are interesting when considering dispersion-dependent Hodgkin and Huxely
models (76a).
In terms of the network activity, little is known regarding the biological effects
of TMS or tDCS. Currently, only one single network model of TMS (77) exists, accounting for more than 33000 neurons with approximately 5 million modeled synaptic
connections, which clearly reproduces many experimental TMS results. Although
Essers model begins to explore network dynamic effects of TMS, future expansions of
the model will clearly bring insight into the network dynamics of stimulation and the
future therapeutic applications of TMS. As discussed below, 2-DG imaging studies
of rTMS in animals have clearly demonstrated that network effects are not physiologically conned to one brain site (78). However, no quantitative model has been
developed that clearly explains the role that rTMS plays in altering cortical, and thus
network, excitability. The network effects of tDCs have been similarly underexplored.
Regrettably, there is no clear understanding of the true biophysical dynamics of
TMS or tDCS. With TMS, the models that exist bring up many relevant issues,
but unfortunately they have not been tested on a cellular level owing to the technical
difculties associated with the process. Until a methodology that will not be corrupted
by the eld artifact is implemented, analogies between microstimulation and TMS
will be the primary approach on which researchers have to rely. With tDCS, little work
has been done to ascertain the cellular effects of the weak currents. The technological
hurdles that exist with TMS are not present with tDCS. Hopefully, future work will
shed more light on both processes.

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INSIGHTS FROM ANIMAL EXPERIMENTS

One of the most surprising aspects of noninvasive brain stimulation methods such
as TMS and tDCS is that their scientic and clinical applications have largely
precededinstead of followedan extensive development of animal models aimed
at determining the details of their neurobiological effects. This could be understandable given their lack of invasiveness and apparent short duration of their effects in the
intact human brain. However, as a result, the understanding of the detailed spatial
and temporal dynamics of specic patterns of stimulation and their detailed neurobiological effects remains insufcient. Given the progressive mainstream spread of
TMS- and tDCS-based therapeutic approaches, the use of adequate animal models
to preassess the effectiveness and long-term safety of increasingly aggressive therapies becomes a real need. A useful animal model needs to allow for the combination
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of a precise and reliable stimulation method with monitoring tools of high spatial
and temporal resolution to capture the physiologic impact. Monitoring methods of
high spatial resolution include metabolic/pharmacologic labeling, optical imaging,
and high-eld functional magnetic resonance imaging (fMRI). Monitoring methods
of high temporal resolution are eld- or single-unit electrophysiological recordings.
Ideally, both of these types of monitoring methods should be combined and applied
simultaneously. Furthermore, an ideal animal model should allow for the exploration
of the behavioral correlates of the stimulation in the awake, freely moving animal.
A pre-existing knowledge on the anatomical connectivity between regions and the
effects of other types of brain manipulation in the same regions, such as lesion studies,
pharmacologic deactivations, microstimulation, or cooling deactivations, is obviously
enormously helpful in the interpretation of the results, helping to rule out potential
epiphenomena.
Rodents (7986), felines (78, 8791), and in a very limited fashion nonhuman
primates (92) have been used in TMS studies aimed at understanding the physiology underlying its effects. Excluding some of the pioneer reports (46, 54), recent
equivalent studies using tDCS remain scarce and are limited to testing its therapeutic effects in rodent models of migraine and epilepsy (93, 94). Especially for TMS,
the ratio between head size and coil size remains the main issue precluding an easy
interpretation and transferability of animal results into human applications because
the induced current density distribution and the spatial selectivity of the impact are
strongly affected by the thickness and size of the brain (95). This is particularly critical for rodent models, in which spatially selective repetitive stimulation of specic
neural networks will remain unfeasible, unless smaller TMS coils can be designed
(85, 86, 96). The limited number of nonhuman primate TMS experiments can be
explained by its high cost, the difculties in training such species to calmly tolerate
periods of stimulation, and the continuous twitching induced by TMS pulses in their
powerful jaw muscles, thus it needs further development. By using an acceptable coil
size/brain size ratio, the cat model has provided the most valuable body of data on
the underpinnings of TMS impact.
In the anesthetized animal, Funke et al. reported the rst direct evidence on how
TMS single or double pulses interfere with the ring of specic visual neurons
tuned to the processing of a given orientation, eliciting different episodes of enhanced (<500 ms post TMS pulse) and suppressed activity (from 500 s to a few
seconds) (87, 88). Those patterns proved to be pulse-intensity dependent, so that
higher stimulation generated an additional early suppression wave of 100200 ms
duration. In spite of their temporal accuracy, such localized single-unit recordings
are blind to the contribution of local and distant re-entry mechanisms, which might
operate such complex and long-lasting suppression-activation dynamics, resulting in
lasting neuromodulation. Using a different approach, Valero-Cabre et al. (78) combined rTMS stimulation in extrastriate parietal regions involved in spatial processing,
with 2-deoxyglucose uptake labeling of the whole brain volume. Taking advantage of
their high spatial resolution (100 m), those studies provided direct evidence of the
network effects of cortical rTMS on an extended network of cortical, subcortical, and
midbrain nodes linked by specic anatomical pathways (Figure 5). High-frequency
fMRI: functional magnetic

resonance imaging
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2 mm
nCi
g-1
A1
663
rT
VP
585
510
SS
A17
A19
SS

443
A
SV
383
316
246
WM
193
nCi g-1
146
663
585
P
N
LG
510
LP
443
SC
383
316
MGN
246
193
146
2 mm
2 mm
Direct local rTMS impact

Connectivity-mediated impact
Figure 5
Local and network effects of on-line rTMS on neural systems in cats. (a) 14 C-2 deoxyglucose
(2DG) uptake image from a cat brain submitted to 20 Hz rTMS on the left visuo-parietal (VP)
cortex which is located at both sides of the suprasylvian sulcus (SS). This region is homolog to
human posterior parietal regions and is involved in spatial processing. Note the differences
between the stimulated and the nonstimulated regions in the contralateral hemisphere.
Regions of the VP are directly targeted by rTMS stimulation (squares). Other regionsSVA,
CVA, A18, A19 and A17are transynaptically deactivated by the reduction of the excitatory
drive exerted from the VP cortical areas targeted with rTMS (circles). VP = visuo-parietal
cortex; SS = suprasylvian sulcus; A17, A18 and A19 = primary visual areas 17, 18 and 19;
SVA = splenial visual area; CVA = cingulate visual area; WM = white matter tracts.
(b) Detail of connectivity-mediated rTMS transynaptic deactivation on the supercial layers of
the superior colliculus (SC) of the same side of the targeted VP cortex. (c) Levels of 14 C-2DG
activity in the posterior thalamic nuclei (such as P and LP) of subjects that received unilateral
rTMS onto the VP cortex of the same side. Regions holding no connectivity with the VP
cortical region do not reveal any signicant difference in glucose metabolic activity. Levels of
2-DG uptake are measured in nCi g1 of tissue, represented by the color spectrums next to
each image. P = pulvinar, LP = lateral posterior complex, LGN = lateral geniculate
nucleus, MGN = medial geniculate nucleus. Modied from Reference 78.
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stimulation generated a mean 14% decrease in cortical activity, affecting a radial area
of 12 mm2 (Figure 6a) and a 1.25% attenuation effect per each mm of cortical
depth across a sulcus separating two banks of cortex (Figure 6b).
Further ndings demonstrated that local and transynaptic effects of TMS depend
on stimulation frequency and time of the assessment in a rather complex way. During
the delivery of the TMS pulses (on line impact), cortical activity is strongly locally
depressed, inducing prominent transynaptic effects. This is likely to be the result
of signicant pools of the targeted cortical neurons being repetitively depolarized,
thus interfering with their normal encoding ring rhythms. Opposite modulation in
cortical metabolism dependent on stimulation frequency patterns were found, outlasting the delivery of TMS trains (off-line impact or after effects) (90). High- or
low-frequency patterns of stimulation resulted in signicant increases and decreases,
respectively, of local glucose consumption, thus providing support to uses of rTMS
in neuromodulation of brain systems (Figure 7). These results are in agreement with
similar and recent cat studies using EEG and evoked visual potentials (91). This
frequency-dependent effect seems to suggest LTP-, LTD-like modulation of the targeted systems (80, 97, 98) and might also reect the contribution of compensatory
mechanisms emerging from untouched brain networks (99). The majority of such
invasive studies are mainly performed in the anesthetized animal, ruling out behavioral
and nonspecic TMS side-effects. Congruent behavioral and metabolic correlates of
similar stimulation patterns are being explored in awake intact and brain-injured cats.
Transcranial DC stimulation has proven to induce both immediate and longlasting changes through a completely different set of mechanisms. According to early
studies in rodents, tDCS generates single-unit ring enhancements during surface
anodal stimulation and decreases during cathodal stimulation (46, 54). These effects
are thought to be mediated by changes in the resting membrane potential of the
stimulated region, but the spatial resolution of the effects and its potential network
impact remains to be studied in detail in larger animals using analogue neuroimaging
and electrophysiological methods, as those reported for TMS.
Animal models will be instrumental to further understand the impact of noninvasive brain stimulation techniques, to optimize scientic and clinical applications of
these techniques, and to test emerging technologies and ensure their safety. Thus,
future endeavors need to explore the use of awake performing animals, such as cats
or possibly nonhuman primates, and combine whole-brain, high-resolution imaging
techniques, such as fMRI, with multielectrode eld and/or single-unit recordings.
MERGING TMS WITH OTHER BRAIN-IMAGING METHODS

IN HUMANS
Merging TMS with other brain-imaging techniques provides particularly powerful
means to explore brain function in the living human brain, understand brain-behavior
relations, and optimize the impact of brain stimulation techniques. Insights from such
experimental approaches can meaningfully be contrasted with results from animal
experiments and guide further sophistication and testing of modeling approaches.
Electroencephalography (EEG) and evoked potentials offer exquisite temporal
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20
20
VP1
VP2
10
2DG (%)
2DG (%)
10
0
10
30
10
20
0.5
1.0
1.5
30
2.0
0.5
Distance (cm)
1.0
1.5
2.0
Distance (cm)
20
SHAM
2DG (%)
10
0
10
20
30
0.5
1.0
1.5
5 mm
2.0
Distance (cm)
rTM
Reduction in 2DG decrease (%)

0
Distance (mm)

20
10
15
20
12
10
VP
1
2
1
SS
3
5
VP1
1.53% loss/mm depth
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resolution and direct measures of neuronal activity. fMRI delivers maximal spatial
resolution. Positron emission tomography (PET) can be used to measure glucose or
neurotransmitter receptor uptake to gain insights into the metabolic impact of brain
stimulation. Optical brain imaging, single-positron emission tomography, diffusion
tensor imaging (DTI), and other brain imaging modalities also offer unique advantages. As proposed by Paus (100), it is possible to combine TMS or tDCS with various
other brain imaging methods before, during, or after the stimulation.
Brain imaging before noninvasive brain stimulation techniques has as its principal
objective the improved planning and precise guiding of the stimulation. MRI can be
used in combination with stereotactic systems to dene and monitor the site of stimulation. Functional information derived, for example, from fMRI, SPECT, or PET
can be overlaid onto anatomical MRI information and be used to dene the target of
noninvasive stimulation techniques. In this context, it is important to remember the
possible limitations of projections of the main stimulation vector and the desirable
benet of more realistic models of induced currents in the human brain, particularly
in the setting of brain pathologies (see above). Nonetheless, using such approaches,
it is possible to use noninvasive brain stimulation to add causal information to the
otherwise purely correlational insights of functional brain imaging. Furthermore,
the use of EEG or evoked potentials can provide valuable temporal information as to
when to deliver a stimulation pulse to maximize a desired behavioral impact.
The use of brain imaging after noninvasive brain stimulation (TMS or tDCS) is
primarily aimed at revealing the changes in brain activity induced by the stimulation.
Obviously, the stimulation will induce behavioral changes and thus the demonstrated
changes in brain imaging will be a complex interplay of the correlates of the stimulation itself, the neurophysiologic consequences of the behavioral changes, and the
response of the brain to such behavioral changes. Careful experimental designs are
thus critical to isolate the desired measures. These challenges are further compounded
by the fact that the combination of any brain-imaging method with TMS or tDCS is
technically challenging and poses unique engineering difculties owing to the risk of
artifact. Such artifacts can obscure the brain imaging measures immediately after the
brain stimulation and become a lot more troublesome for studies of brain imaging
during TMS or tDCS.
PET: positron emission

tomography
DTI: diffusion tensor
imaging
Figure 6
(a) Correlation plots showing the individual percent change ( ) between stimulated and
unstimulated VP cortex, beginning at 0.0 cm in the posterior end of the suprasylvian sulcus
(SS) to a distance 2.0 cm forward in the brain. The arrow shows the direction of data sampling
in the VP cortex, presented in the correlation plots. We present data from two cats stimulated
with real rTMS on VP (VP1, VP2), and a control animal (SHAM) stimulated with sham
) indicate the exact site of
rTMS at the same region. The concentric circles (
TMS stimulation in the visuoparietal cortex (shaded region). Modied from Reference 78.
(b) Notice the decay in the rTMS induced reduction of cortical metabolism generated on VP
cortex. No signicant changes in 2DG uptake were detected during sham rTMS stimulation.
Regression functions for both animals allowed us to estimate the spatial resolution of our
stimulation, i.e., the distance to complete loss of rTMS signicant effect in the order of
1015 mm. Modied from Reference 78.
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a rTMS
nCi g-1
663
510
Low
585
2 mm
SS
443
246
SS
High

383
316
* *
2DG uptake (%)
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VP3
VP4
0
VP1
VP2
2
4
6
193
* *
146
High-frequency rTMS
Low-frequency rTMS
2DG uptake (nCi g-1)

Figure 7
(a) Representative color-coded 14 [C]-2-deoxyglucose (2DG) uptake images and average
histograms from a pool of four adult cats (subjects VP1-VP4) that received either high- (VP1,
VP2) or low-frequency (VP3, VP4) rTMS stimulation patterns on the visuo-parietal (VP)
cortex. Notice the intense long-lasting decrease of 2DG at the stimulated VP ( ) in respect to
its contralateral counterpart after 20 min of high-frequency rTMS. Also note the decrease
induced after the same period of continuous stimulation at low frequency. The impact of both
interventions is much milder than that generated by on-line high-frequency stimulation, as
shown in Figure 5, which is represented in an identical 2DG level scale. The asterisks ( )
indicate the position of the rTMS coil located on the scalp right above the so-called
suprasylvian sulcus (SS). (b) Histogram displaying the average percent change ( ) in 2DG
uptake after the application of high (red ) or low (blue) frequency trains at parietal regions of
four cats. Changes in local metabolic activity affected primarily the supercial regions of the
crown of the SS. The deeper the region, the lower the change in activity that is produced.
Detailed analysis demonstrates that the region of signicant off-line rTMS impact extended
1.5 to 1.8 mm2 around VP. These data indicate that high-frequency stimulation induces
extended increases of activity. On the contrary, low-frequency rTMS results in long-lasting
metabolic decreases across the same region. Additionally, white matter or subcortical or
distant effects were only rarely noted, thus indicating the long-lasting rTMS impact is mainly
locally restricted to the targeted VP region. For both paradigms, sham TMS stimulation
resulted in no changes in cortical 2DG uptake. Modied from Reference 48.
TMS and EEG

EEG was the rst technique to be explored in combination with TMS (101). EEG
provides exquisite temporal resolution and a direct measure of neuronal activity, and it
is capable of differentiating between inhibitory and facilitatory effects. Initial studies
combined EEG and TMS to study functional alterations at regions distant (in time
and space) to magnetic stimulation via an analysis of altered EEG patterns. For example, it was possible to provide in vivo measures of transcallosal and fronto-parietal
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interactions (102, 103). However, the value of the results was limited by the quality of the EEG signal, excessively distorted by artifacts related to the TMS pulses.
Problems related to the saturation of the EEG-recording ampliers from the TMS
pulse have been overcome by artifact subtraction and pin-and-hold circuits, and by
altering the slew rate of the preampliers. Thanks to these developments, it is now
possible to analyze the EEG online with TMS stimulation (104, 105). This allows
for the analysis of the effects of TMS on task-related electrophysiological recordings
and provides information on various functional aspects of the large-scale networks involved in cognition, including feed-forward and feed-back mechanisms of functional
signal transmission. It is clear that TMS-induced neuronal activity spreads beyond
the directly stimulated area to anatomically connected sites and thus TMS ultimately
induces a modulation of a specic, cortico-subcortical, bihemispheric neural network.
Behavioral effects of TMS over a given brain area reect how the distributed neural
network (and the rest of the brain) reacts and compensates for the transient cortical
disruption during task execution. The behavioral effects of TMS critically depend on
anatomical and functional connectivity of the stimulated area, on the excitatory and
inhibitory interplay between target area and connected sites while subjects carry out
a given task, on the orchestration of serial and parallel processes across the regions
operating in concert for task execution, and on the possibility to tap into functions
whose neural bases were left unaffected by TMS. Therefore, precise control of the
behavioral effects of TMS in a given individual requires (a) precise and consistent
targeting of a dened brain region and (b) timing the stimulation and setting the
stimulation parameters so as to guide activity in the targeted brain region and its
connected neural network in a predictable and desired fashion. Timing the stimulation and setting its parameters so as to induce a dened modulation of activity in
a distributed neural network requires online monitoring of the brain activity. Combined EEG-TMS techniques provide neuroscientists with a unique method to test
hypotheses on functional connectivity, as well as on mechanisms of functional orchestration, reorganization, and plasticity. Combination of TMS with EEG can also
serve to increase the safety of brain stimulation when parameters fall close to the recommended safety guidelines. Furthermore, EEG guidance of the TMS parameters
can provide a means to optimize the timing of the TMS on the basis of the subjects
temporary state of brain activity and thus maximize the achieved behavioral impact.
Figure 8 schematically summarizes a system for EEG-controlled TMS.
TMS and PET

PET can demonstrate changes in regional cerebral blood ow (rCBF) following
TMS as initially shown by Paus et al. (106). PET offers the advantage of capturing
cortical and subcortical activity simultaneously in the whole brain. One of the main
technical difculties faced in combining PET with TMS is the possible interference
of the strong magnetic eld of TMS with the photomultipliers of the gamma camera
(sensitive to magnetic elds of approximately 104 T versus the nearly 2 T generated
by TMS). To protect the gamma camera, Paus et al. shielded the photomultipliers
with four layers of 0.5-mm-thick mu-metal. The homogenous thickness and density of
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Figure 8

(a) TMS-induced amplier

saturation of EEG signal;
(b) EEG signal; (c) combined
TMS-EEG system.
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the shield is critical to prevent the appearance of artifacts in the images. However, the
images are attenuated by approximately 22%, which might obscure some meaningful
effects (100, 106, 107). In the meantime, the need for the use of a mu-metal shield
has been challenged in other studies and it appears unnecessary (108, 109).
A number of authors have employed PET-TMS combinations to measure rCBF
changes in response to TMS. Paus et al. (106) and Lee et al. (109) demonstrated a
positive correlation between the number of TMS pulses and the rCBF changes in
the targeted brain region as measured by PET. Siebner et al. studied the inuence of
different stimulation frequencies on rCBF (110). Negative correlations, suggestive of
inhibitory effects of the stimulation, can be induced by specic patterns of rTMS (111)
and network effects can be clearly demonstrated. For example, Speer et al. (112, 113)
studied the effects of different stimulation intensities to prefrontal or motor cortex.
In both studies, they demonstrated specic local changes in the targeted brain region
and cortical and subcortical impact of selective neural structures. It is postulated that
rCBF changes distal to the coil focus reect functional connectivity and proximal
changes reect changes in cortical excitability.
As a measure of rCBF, the utility of PET may be limited. Regional CBF measures
offer only indirect insights into neuronal impact of the stimulation. Furthermore,
fMRI has a superior spatial resolution and allows for repeated, safe testing. However,
FDG- and tracer-PET can provide unique insights into the metabolic effects of the
stimulation and reveal direct physiologic information about mechanisms of action in
the living human brain.
For example, Strafella et al. (114116) pioneered the use of [11 C]-raclopride
tracer PET to demonstrate changes in extracellular dopamine concentrations following rTMS. They extended this research to study the role of striatal dopamine
release in Parkinsonian patients following TMS, demonstrating clear differences in
the release between the symptomatic hemisphere and the asymptomatic hemisphere
in the presymptomatic stage of Parkinsonian subjects (116). In addition to studies
in Parkinsons disease, combined PET and TMS methodologies have been implemented, for example, in the study of depression (117), stroke (118, 119), or tinnitus
(120). Tracer PET studies in such instances might be invaluable to guide therapeutic interventions and optimize stimulation parameters. For instance, in Parkinsonian
patients, the dopamine differences between hemispheres could be used as a baseline
to guide therapy and/or to monitor disease progression. Combined PET and TMS
data can be utilized to generate network models and demonstrate the fundamental
effects of brain stimulation on large-scale neural networks (121).
TMS and SPECT

Multiple single-photon emission computed tomography (SPECT) studies have been
run in conjunction with TMS, where SPECT measurements are normally taken
following administration of TMS to analyze rCBF, similar to the PET studies outlined above (122). In this fashion, SPECT is hampered by poorer spatial resolution
than PET, but has the advantage of greater accessibility and lower cost. Importantly
though, similar to the PET studies of Strafella et al., tracer-based SPECT systems
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have provided researchers with the ability to capture the impact of TMS on specic
neurotransmitter systems. Pogarell et al. studied the use of IBZM SPECT as a means
to study the effects of rTMS on dopaminergic neurotransmission by analyzing the
degree of striatal IBZM binding to dopamine D2 receptors with a region-of-interest
(ROI) technique (123). Other developments in this direction are surely desirable.
ROI: region-of-interest
TMS and NIRS

Near infrared spectroscopy (NIRS) has allowed researchers to study brain

hemoglobin levels in the coil region during and after TMS stimulation with temporal resolution (125 ms) second only to EEG, as has been demonstrated by Hada
et al. (124) and Noguchi et al. (124a,b). Noguchi et al. extended the conventional
NIRS technique by increasing the number of light emitter and detector pairs (a single pair is normally used in NIRS) that are capable of measuring optical changes
in tissue brought about by hemoglobin concentration changes. They thus increased
the signal-to-noise ratio of the technique such that it was capable of demonstrating
both subthreshold and suprathreshold single-pulse TMS alterations in cortical oxyhemoglobin levels. Hada et al. (124) extended this technique to rTMS. As it is an
optical technique, NIRS has the advantage of being relatively immune to any major electromagnetic artifact from the TMS and to allow the imaging of the cortical
mantel, i.e., the main brain region of the TMS impact.
TMS and fMRI

Of all noninvasive imaging modalities, fMRI provides the clearest insight into the
regions of the brain affected during TMS. In conjunction with TMS, fMRI provides
better spatial resolution than EEG, SPECT, or PET and has a superior temporal resolution than all of the modalities except for EEG. Initially, researchers thought that
limitations related to the synchronization of the fMRI slice acquisition with the TMS
pulse and the signal noise caused by the TMS coil would be too difcult to overcome
when combining the techniques. However, Bohning et al. (125127) successfully imaged the blood oxygenation level-dependent (BOLD) signal during combined TMS
and fMRI, and since this pioneering study, further improvements have been made
that have focused on fMRI slice acquisition (orientation and timing), reduction of
signal loss owing to the TMS coil, and removal of the artifacts caused by the TMS
coil (128134). Even with these improvements, there has still been great difculty in
resolving the BOLD signal directly under the TMS coil (for a review see Reference
131). Nevertheless, multimodal studies combining fMRI and TMS directed at visualizing the effects of TMS over the distributed cortex, between cortico-cortico connections, and cortico-subcortical connections have proven powerful and fruitful, and
work continues on elucidating the BOLD signal in the TMS coil region (Figure 9).
tDCS
tDCS has been combined with EEG (135137), PET (138), and fMRI (128). The
technical challenges of combining tDCS with other techniques are less difcult to
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Figure 9
Depictions of fMRI and TMS, showing (a) anatomical MRI with coil representation, where
the coil is centered above the primary visual cortex and in the inset the TMS coil is
highlighted with vitamin E pills, and (b) fMRI BOLD activity evoked from single-pulse TMS
on the primary visual cortex.
overcome than those of TMS, as no large stimulation artifact exists with tDCS.
Ardolino et al. (135) studied the after-effects of tDCS (10 min, 1.5 mA cathodal
stimulation to right motor cortex) on the EEG and found signicant effects on the
total power, delta, and theta activity, but statistically insignicant changes in the power
of the alpha and beta/gamma rhythms with a two-way ANOVA analysis. They also
assessed the affects of tDCS on spontaneous EEG activity, nding increased theta
and delta rhythms indicative of large-scale network changes outside the region of the
tDCS focus. Other researchers combined these modalities while studying sleep (136)
and visual processes (137). Lang et al. (138) used PET to show widespread changes in
rCBF in cortical and subcortical regions post tDCS (1 mA, 10 min), again indicative
of the large-scale network changes brought about by tDCS. Baudewig et al. (128)
studied the effects of tDCS on the fMRI BOLD signal both 5 and 1520 min after
a 5 min period of 1 mA stimulation. They found a signicant increase in the mean
number of activated pixels, which decayed with time following cathodal stimulation,
while anodal stimulation accounted for a 5% nonsignicant change.
FUTURE DIRECTIONS AND CONCLUSIONS

Noninvasive brain stimulation has undergone a remarkable evolution since its inception. Today, scientists and physicians have the ability to explore the foundations
of brain function and may ultimately alleviate numerous neuropsychiatric ailments
with the controlled application of electromagnetic energy. The stimulator technology currently available has allowed the development of potentially more effective
neuromodulatory patterns of stimulation (98, 139). Both TMS and tDCS have been
coupled with imaging modalities (EEG, PET, fMRI, etc.), furthering our understanding of these stimulation techniques and providing clinicians with further means to
assess neurological pathologies, reveal pathophysiology of disease, and understand
mechanisms of action of brain stimulation. Nevertheless, even with all of these improvements, there are still many ongoing and future innovations that are necessary
to take brain stimulation into the future.
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The development of new and improved stimulator technology is an area of ongoing study and presents numerous challenges for biomedical and electrical engineers.
In the area of TMS device design, advancements are continuously being made to
increase the machine pulse frequencies. With ever increasing frequencies, problems
related to coil heating become even more difcult to address; the current solutions
implement air- or liquid-cooling mechanisms. However, it is possible that future developments could be implemented using TMS coils made of materials with lower
specic heat, implementing novel heat sink strategies, or using gas-cooled TMS coil
systems similar to modern MRI (however, such a system would be impractical with
current technologies available).
There are many ongoing projects to improve on the current TMS tracking technology. To account for cortical current perturbations seen in neuropathologies that
are not accounted for with conventional tracking systems, our group is integrating a
tracking system with an FEM electromagnetic eld solver based on individual patient
MRIs, whereby the patients anatomical MRI data and their tissue electromagnetic
properties are mapped into the FEM mesh space. In practice, this technique will allow
clinicians and researchers to predict the location, orientation, and magnitude of the
induced stimulating current densities in individual patients based on individualized
tissue heterogeneities, anisotropies, and dispersive properties. This control will allow one to ascertain the effects of pathological processes on TMS-induced current
densities.
New imaging technologies are being developed that may eventually be fruitful to
combine it in multimodal approaches with TMS or tDCS. For example, diffusion
spectrum imaging (DSI) can provide critical insights into the conductivity of various
brain tissues and can be used to improve the localization of EEG and magnetoencephalogram (MEG) sources. DSI provides information about ber orientations
in the white matter and the anisotropic conductivity of tissues. Thus, this technology
could be used to investigate the orientation specicity of TMS and allow us to compare TMS with electromagnetic models of the brain that include interactions with
neuronal subpopulations in gray matter and subcortical white matter resolved with
DSI. This would allow one to test the potential neuroanatomic selectivity of TMS
and assess the orientation-sensitivity of axonal reactivity to TMS, given the typical
fanning orientations of subcortical white matter.
As knowledge of TMS effects on various pathologies is gained, devices have been
proposed that are targeted for specic clinical implementation. Common to most
therapeutic application of rTMS is the fact that stimulation has to be applied repeatedly for consecutive days (generally 10 to 20 days) in daily or even bidaily sessions.
Under current methodology and practice, this means that patients have to go to the
doctors ofce or laboratory daily. It may also be better for rTMS treatment effectiveness to be delivered for a longer period of time or for short periods of time but more
frequently. Therefore, self-delivery of rTMS by the patient in his home environment
may be far more effective and certainly would provide a much more exible and individualizable protocol. One may therefore envision modular, portable TMS devices
that are capable of being tted to the patients own headshape, incorporate the TMS
coils so as to target the desired brain region in the patient, and are controllable by
DSI: diffusion spectrum

imaging

MEG:
magneto-encephalogram
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telecommunications channels to tailor treatment to individuals. Such a device could

prove very useful in the long-term treatment regiments of TMS for such ailments
as depression. Other portable devices have been proposed for more acute treatment
regiments; for example, a portable hand-held TMS device for self-administered stimulation for migraine treatment is being tested. In the area of epilepsy treatment,
delivery of the TMS pulse at the precise time following an epileptic spike is likely
critical, and thus, high frequency of stimulation (>100 Hz) and EEG-triggering of
the stimulation would seem desirable. For such a purpose, a stimulation coil system
with built-in EEG monitoring capabilities and appropriate EEG-control circuitry
would seem advantageous.
As tDCS has been rapidly growing over the past ve years, numerous improvements have been proposed and certainly will be implemented in future studies. tDCS
offers a low-cost, potentially high-impact option for various pathologies that could
easily become mainstream in home use for neurorehabilitation and neuropsychiatric treatments. Device improvements have been proposed to develop integrated
tracking systems with tDCS solvers to predict stimulation sites based on relative
electrode schemes, to implement multipolar electrode schemes to increase focality,
and to add levels of biofeedback and control via online EEG monitoring. As more
clinical knowledge is obtained, devices could be designed for home use with patientspecic parameters programmed into the device (i.e., timing and current amplitude
of treatment).
Finally, TMS and tDCS both suffer from limited focality. For TMS, increased
focality has been explored with unique coil shapes, smaller coils, and conductive
shields, as explained above. For tDCS, investigators have proposed multipolar electrode schemes to superimpose elds to achieve increased focality. In addition to the
limited focality of both techniques, neither offers a means to stimulate the brain
subcortically, without maximally stimulating the cortical surface. These limitations
represent an area of open study for future biomedical engineers. In addition to providing motivation for the future development of current TMS and tDCS technologies,
these limitations provide even further motivation in the development of new modalities for noninvasive stimulation. Acoustic (140143), microwave (144), extremely
low-frequency magnetic elds (145), and pseudo-invasive combined methods (146)
have been explored with varied levels of success. The challenge of developing a noninvasive method for focal deep-brain stimulation remains an important and challenging
focus of research.
DISCLOSURE STATEMENT
Dr. Pascual-Leone has previously received grant funding from Magnatism Corp. He
also holds patents on TMS and MRI, and TMS and EEG combinations.
ACKNOWLEDGMENTS
The work on this article was partly supported by CIMIT and NIH grants K24
RR018875, RO1-EY12091, RO1-DC05672, RO1-NS 47754, RO1-NS 20068,
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R01-EB 005047, RO1-NS47754, and RO3-EY014588. AV-C was supported by

grants from La Caixa (Spain) and the Spanish Ministry of Education, Culture, and
Sports (EX2002-041). Large parts of the work summarized in this article were conducted with the invaluable collaboration of M. Zahn and A. Grodzinski. We thank
M. Thivierge for the expert administrative support.
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Contents
Annual Review
of Biomedical
Engineering
Volume 9, 2007
Cell Mechanics: Integrating Cell Responses to Mechanical Stimuli

Paul A. Janmey and Christopher A. McCulloch p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
Engineering Approaches to Biomanipulation
Jaydev P. Desai, Anand Pillarisetti, and Ari D. Brooks p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 35
Forensic Injury Biomechanics
Wilson C. Hayes, Mark S. Erickson, and Erik D. Power p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 55
Genetic Engineering for Skeletal Regenerative Medicine
Charles A. Gersbach, Jennifer E. Phillips, and Andrs J. Garca p p p p p p p p p p p p p p p p p p p p p p 87
The Structure and Function of the Endothelial Glycocalyx Layer
Sheldon Weinbaum, John M. Tarbell, and Edward R. Damiano p p p p p p p p p p p p p p p p p p p p p p121
Fluid-Structure Interaction Analyses of Stented Abdominal Aortic
Aneurysms
C. Kleinstreuer, Z. Li, and M.A. Farber p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p169
Analysis of Time-Series Gene Expression Data: Methods, Challenges,
and Opportunities
I.P. Androulakis, E. Yang, and R.R. Almon p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p205
Interstitial Flow and Its Effects in Soft Tissues
Melody A. Swartz and Mark E. Fleury p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p229
Nanotechnology Applications in Cancer
Shuming Nie, Yun Xing, Gloria J. Kim, and Jonathan W. Simons p p p p p p p p p p p p p p p p p p257
SNP Genotyping: Technologies and Biomedical Applications
Sobin Kim and Ashish Misra p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p289
Current State of Imaging Protein-Protein Interactions In Vivo with
Genetically Encoded Reporters
Victor Villalobos, Snehal Naik, and David Piwnica-Worms p p p p p p p p p p p p p p p p p p p p p p p p p p p321
Magnetic ResonanceCompatible Robotic and Mechatronics Systems
for Image-Guided Interventions and Rehabilitation: A Review Study
Nikolaos V. Tsekos, Azadeh Khanicheh, Eftychios Christoforou,
and Constantinos Mavroidis p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p351
v
AR317-FM
ARI
7 June 2007
19:9
SQUID-Detected Magnetic Resonance Imaging in Microtesla Fields

John Clarke, Michael Hatridge, and Michael Mole p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p389
Ultrasound Microbubble Contrast Agents: Fundamentals and
Application to Gene and Drug Delivery
Katherine Ferrara, Rachel Pollard, and Mark Borden p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p415
Acoustic Detection of Coronary Artery Disease
John Semmlow and Ketaki Rahalkar p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p449

Computational Anthropomorphic Models of the Human Anatomy:

The Path to Realistic Monte Carlo Modeling in Radiological Sciences
Habib Zaidi and Xie George Xu p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p471
Breast CT
Stephen J. Glick p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p501
Noninvasive Human Brain Stimulation
Timothy Wagner, Antoni Valero-Cabre, and Alvaro Pascual-Leone p p p p p p p p p p p p p p p p p p p527
Design of Health Care Technologies for the Developing World
Robert A. Malkin p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p567
Indexes
Cumulative Index of Contributing Authors, Volumes 19 p p p p p p p p p p p p p p p p p p p p p p p p p p p589
Cumulative Index of Chapter Titles, Volumes 19 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p593
Errata
An online log of corrections to Annual Review of Biomedical Engineering chapters
(if any, 1977 to the present) may be found at http://bioeng.annualreviews.org/
vi
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